Resuscitationist lessons from a self-protection master

“It’s better to have it and not need it, than to need it and not have it“

My great friend and fellow Brit Lee Morrison is in Sydney again, teaching people how to save lives. Like a resuscitationist. But Lee isn’t a health care worker. He is a professional self protection instructor and martial athlete. The lives he is teaching people to save are their own and those of their friends and families. Lee has travelled the world and taught a diverse range of professionals including law enforcement and military special forces personnel. His current world tour will include the Czech Republic, USA, France, Russia and Germany after Australia.

What does this have to do with resuscitation? In my experience, almost everything. Hitting someone in self defence is technically very easy. Doing a resuscitative hysterotomy is technically very easy. Being able to do either of those things under stress can be difficult or impossible for some people.

Those who strive to understand and cultivate the Mind of the Resuscitationist know the importance of preparation through simulation under stress; the need to acknowledge and control the physiological and emotional response to stress; the necessity to train outside ones comfort zone and minimise the gap between simulated and real situations by optimising the cognitive fidelity of training scenarios; and the requirement to access the right mental state in an instant in which failure is not considered to be an option.

People who do not wish to witness the discussion or demonstration of violence or who cannot stand swearing should stop now. Those of you who want to see mastery in action watch the video below of Lee teaching in Germany.

I want you to appreciate the following:

Presentation style – how to connect with an audience and fully engage them through humour, passion, emphasis, intelligent discourse, and detailed explanations that connect emotionally and physically as well as intellectually.

The loss of fine motor skill under stress (2 min 13 sec)

The mindset of determination (2 min 48 sec) – consider how this relates to the perspective of the resuscitationist prepared to do a resuscitative thoracotomy under stress

How to influence and win arguments in a conflict situation by being assertive but providing a face-saving get-out for the aggressor. I have applied this multiple times in the resus room and in retrieval situations. (4 min 11 sec)

Training honestly – maintaining safety but ‘doing it like you f—-ing mean it’. Get out of your comfort zone and make the discomfort as real as possible. (7 min 37 sec)

How to minimise the gap between your training and what you’re training for, when legal, moral, and safety restrictions prevent you from doing the actual task for real as a training exercise. Using fatigue, pain, and disorientation as perturbations so you learn to recognise and mitigate their effects. (9 min 19 sec)

Accessing a single mental state that provides focus and prevents distraction from discomfort (11 min 40 sec)

If the video made you feel uncomfortable ask yourself why. If it’s because you consider yourself to be above violence and find the subject matter, language, and humour to be distasteful, that’s your right to feel like that. But try to dig a little deeper and ask yourself whether there are potential situations in your life that could confront you with fear or pain that you could be better prepared for if you trained with a different mindset.

When the situation arises that demands life-saving action and you are tired, hungry, scared, and discouraged by opposing advice or opinion, do you have the self-knowledge and resilience to see it through? If you don’t know the answer to that, isn’t it time you found out?

13 thoughts on “Resuscitationist lessons from a self-protection master”

Hey Cliff.
A great video on some mental strategies and techniques for someone getting assaulted.
I’ve watched it twice now and thought about it in conjunction with your bulletpoints.

My own feeling though, is that the video really itself does not have much to offer with respect to any strategies or behaviours, or even concepts I would want to see in any resuscitation room. Teaching ‘the mind of the resuscitationist’ in the context of aggression and violence is not an accurate simulation of the stress or experiences faced by the resus team (well maybe occasionally).

Personally, I have found many of your talks to be inspirational.
But I feel there is a risk of a macho militarisation style creeping into resuscitation team skill teaching.

For me it is more ‘mind like water’ and less ‘do it like you fucking mean it’.

Thanks Ian. I appreciate it’s not for everyone. In my mind, the ‘do it like you …. mean it’ refers to the training phase of resuscitation. We must commit to optimising cognitive and physiological fidelity or we will not be truly prepared when an extremely challenging situation arises. Aggression and violence are abhorrent but I do feel on a personal level that preparing for them through training has helped me develop attributes and understanding that has assisted me in my approach to resuscitation, and possibly in producing the work that you kindly say you’ve found inspirational. I guess it’s one of many paths I could have taken that might have led to similar insights. And you know about paths.

Hi Simon thanks for commenting. I have failed to get my point across if you think I’m focusing on aggression. I don’t follow the link between preparing for action under stress and tribal behaviour / poor CRM. The worst examples of that which I’ve seen have been by people clearly unprepared for the situation they’re in.

I also don’t think you need to get whacked around the head unless you want to train for street self defence like the guys in the video. I’m afraid I assumed most people would get that. They are providing an example of preparing themselves for the reality of what they might face. We can learn from that, for example by constructing a surgical airway model that bleeds profusely while an assistant’s (German or otherwise) shaking hands drop a bougie on the floor and another critical simulated patient gets wheeled in. This would more closely resemble reality than training for surgical airways on a clean neck task trainer in a classroom, and the participant would have a better idea of their performance under stress.

Great video I agree Cliff advanced stages of training have got to become more realistic. That doesn’t mean they need to include violence and I’m sure you would agree I don’t think that that was what you were trying to imply with this video.

What I got from this was if you are trying to prepare as a fighter, you have to be faced with somebody who could hurt you. If you are trying to prepare for a stressful resus you have to buy in to the sim; you have to care about what happens to the simulated patient and how your team reacts. Training is no good if when things go wrong the reaction is simply “oh well better luck next time” or “we’ll run this again next week and see how things go” because when it is a real patient/a real fight and it goes wrong there might not be a next time for somebody. What we do matters, we have to train like that matters just as much.

I understand that this material can be upsetting and off-putting to many people. But, after thinking about the video, I think I take three things away from it:

1. Understanding your response to stress and noxious stimuli. You have to know how you are going to react to different stressors. If you are preparing for self defense, you have to know how you respond to being attacked. This has to be extrapolated to a clinical scenario: if you want to prepare yourself to resuscitate the critically ill, perhaps we should engage in scenarios that allow to engage in metacognition and evaluate our response in resuscitation.

2. Mental toughness: knowing that you can survive, knowing that you can keep fighting in the face of adversity and even win. Again, this has to be applied to a clinical setting: knowing that when the deck is stacked against you, when things are going wrong, you can still fight….for your patient’s life…with your clinical skills and decision making abilities.

3. Train like you mean it. If you want to be prepared to perform under very difficult circumstances, train under harsh circustances. For clinicians, this is probably not getting struck in the face, but it may include getting yelled at family members or others.

I have the utmost respect for Simon and Ian’s comments. I would, however, add this. I think there is a difference between the messages posted here in and macho militarism. The dangerous risk of macho militarism and tribal behavior is founded in blind ignorance and a fundamental failure to respect others combined with arrogance. I agree, this should be avoided at all costs. But I do believe that we can take a different message from this post.

Thanks for another thought provoking post. My initial gut reaction, like the others was to question the utility of the metaphor (training for fighting) that you chose to deliver your message. I then took a step back to think about the underlying message you’re trying to get across, and I can see some merit in it. But like the others I have a few concerns.

There is a bit of hype about “stress inoculation” in the FOAMed-sphere currently, but I agree with Ian about the risk of “macho militarisation” of medical training, which personally doesn’t gel with me – nor with many of my colleagues – at all (as I mentioned to Simon over at St Emlyn’s recently!). I think we share a fear that some people who aren’t that au fait with simulation education methods might get carried away and start running their sim sessions like a scene from Full Metal Jacket:

I think if you have good leaders in your department, who can create a culture of excellence, and have the experience to adapt local training to raise everyone’s standards, then go for it. Adding military or “fighting” analogies to it does however risk alienating a lot of people.

There are some studies that show that for certain procedures, high-fidelity simulation is no better than low fidelity methods for procedural skill acquisition. However the translation of these skills into practice is very hard to study and measure. Are there any studies you know of that compare high-stress training with standard teaching for procedural skill performance in medical settings? Do they follow through into application in real life practice? They’d be some interesting studies to design/run!

From my own experience teaching trauma procedural skills and team-based scenarios, participants are already in an adrenalised state when they participate in sim training, and I think that up to a certain level, this heightened state of arousal is an effective stimulus for learning.

It’s possible that adding more adrenaline may just distract and confuse participants and the actual objective (if it is procedural skill acquisition) will be lost. Defining the tipping point from learning to overload, and how you plan to teach learners to handle it, (if this is the objective, rather than procedural skill acquisition) is crucial.

There’s also the risk of harm from setting people up to fail.

There is “evidence” (note quotation marks – it’s a bit wishy washy) from the simulation literature that setting people up to succeed results in better learning outcomes, and poorly designed scenarios in which poor performance (which one assumes would be more likely to occur in hyper-adrenalised situations) resulting in a negative patient outcome in the scenario, can cause PTSD like reactions with profound negative psychological impacts on learners (This is why good sim centres have on-call psychologists on their staff). Adding too much stress to an already adrenalised learner without very clear objectives, experienced instructors to guide the scenario and expert debriefing, thereby stressing them to the point of failure/unintentionally harming the patient will defeat the purpose entirely.

Like Captain Kirk (Thanks Tim L.), I don’t believe in the “no-win scenario”!

Simulation training without prior teaching of the knowledge and skills required to successfully manage the situation you’re about to be exposed to is pointless at best, and at worst, psychologically damaging, if only for the “f-you” reaction people have when they’ve been humiliated, disempowered or set up to fail. Just dropping people into high-stress situations without graded exposure and teaching them skills to handle it, through repetition, visualisation, and non-sim problem solving exercises just to “toughen them up” is a bad idea.

Lee clearly teaches his students skills to handle the high stress situations he puts them in, but I think your message may have been lost in all the punching!

I do totally agree with you and Lee about the effect of adrenaline on performance, and I am a firm believer of the power of repetition, visualisation, knowledge of oneself, the environment the patient and the team, all of which I have learned from you.

Great talk as usual. While I understand the point of view of the others in regards to the violence I thought this talk was spot on. This guy Lee reminds me of another combative instructor Tony Blauer. Blauer is a pioneer in the field of combat psychology discusses many topics such as hicks law and the startle flinch response. I believe these principles can be applied to the field of resus as well as far as fear management and stimulation training goes. Like Bruce lee said once “absorb what is useful, reject what is useless and add specifically what is your own.” I believe we and our patients benefit when we can apply concepts from other fields.

Thanks Andy it’s great to have input from so many accomplished educators. As with any sim or any educational activity I think it helps to be clear about the objectives and to handle it carefully and sensitively. The approaches you caution against are not those my colleagues and I would ever attempt to pursue so I don’t see a lot of real disagreement.

I think there is a clear distinction between the teaching of procedural skills and immersive sim, but I would suggest that if we want the former to be effective they also need to be applied in the latter. How many surgical airways have not been done when indicated despite the clinician having done ‘procedural’ training on an alphabet course? If our training ignores the cognitive and physiological challenges that inevitably accompany the clinical, we do our leaners and their patients a disservice. How we best do that, I agree, requires more research to provide a sound evidence base and this is new ground for medicine, on which we should tread carefully. I have a fairly atypical work setting that amplifies this need – our recruits are fairly senior clinicians accomplished in critical care procedures who are exposed to environmental and human factor stimuli that are new and challenging. We have a responsibility to prepare them as best we can, and enjoy the luxury of a tightly interwoven QA and education structure. Every case is reviewed, and learning points can be fed into the training of a motivated, finite team almost immediately. Clear themes have emerged over the years that have reinforced our passion for focusing on stress prevention and preparedness. We might be at one end of a spectrum of approaches that need to be tailored to the individual learner or work setting so that we make great clinicians, not break them.
Cheers
Cliff

Cliff is not trying to glorify violence here. He has great respect for instructor Lee and has found his teachings to be relevant in his medical work.

Its fair to say, not everyone agrees to the relevance in their medical work or for training.

I havent trained with Cliff’s instructor but have with Tony Blauer..many years ago. You must appreciate these folks come from a different life experience to the average doctor/nurse. If you have ever worked night club security ( I used to) or in policing then you will instantly appreciate that what you see in that video is relevant to you!
If you have ever had an assailant pull a knife at you then you will appreciate what it is like finding yourself in a CICV actual situation. You need to act, or something really bad is about to happen. If you are really good at it,you might be able to talk your way out of a knife attack…but thats a very big IF. You are most certainly NOT going to be able to talk your way out of a CICV situation though!

This is the point Cliff and Lee is trying to make.

Its got nothing to do with glorifying violence or saying who has the biggest Johnson.